Project description:BackgroundThe majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care.ObjectivesAs part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs.MethodsWe conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD.ResultsFrom 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months.ConclusionsThe results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.

Project description:BackgroundPrimary care has the potential to address a large proportion of people's health needs, promote equity, and contain costs, but only if it provides high-quality health services that people want to use. 40 years after the Declaration of Alma-Ata, little is known about the quality of primary care in low-income and middle-income countries. We assessed whether existing facility surveys capture relevant aspects of primary care performance and summarised the quality of primary care in ten low-income and middle-income countries.MethodsWe used Service Provision Assessment surveys, the most comprehensive nationally representative surveys of health systems, to select indicators corresponding to three of the process quality domains (competent systems, evidence-based care, and user experience) identified by the Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals Era. We calculated composite and domain quality scores for first-level primary care facilities across and within ten countries with available facility assessment data (Ethiopia, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda).FindingsData were available for 7049 facilities and 63 869 care visits. There were gaps in measurement of important outcomes such as user experience, health outcomes, and confidence, and processes such as timely action, choice of provider, affordability, ease of use, dignity, privacy, non-discrimination, autonomy, and confidentiality. No information about care competence was available outside maternal and child health. Overall, scores for primary care quality were low (mean 0·41 on a scale of 0 to 1). At a domain level, scores were lowest for user experience, followed by evidence-based care, and then competent systems. At the subdomain level, scores for patient focus, prevention and detection, technical quality of sick-child care, and population-health management were lower than those for other subdomains.InterpretationFacility surveys do not capture key elements of primary care quality. The available measures suggest major gaps in primary care quality. If not addressed, these gaps will limit the contribution of primary care to reaching the ambitious Sustainable Development Goals.FundingBill & Melinda Gates Foundation.

Project description:IntroductionThe private sector plays a substantial role in delivering and financing healthcare in low- and middle-income countries (LMICs). Supporting governments to govern the private sector effectively, and so improve outcomes across the health system, requires an understanding of the evidence base on private health sector governance. This paper reports on a scoping review, which synthesised evidence on the approaches used to govern private sector delivery and financing of healthcare in LMICs, the effectiveness of these approaches and the key enablers and barriers to strengthening governance.MethodsWe undertook a systematic search of databases of published articles and grey literature to identify eligible papers published since 2010, drawing on WHO's governance definition. Data were extracted into a pretested matrix and analysed using narrative synthesis, structured by WHO's six governance behaviours and an additional cross-cutting theme on capacities.Results107 studies were selected as relevant, covering 101 LMICs. Qualitative methods and document/literature review were predominant. The findings demonstrate the relevance of the WHO governance behaviours, but the lack of robust evidence for approaches to implementing them. Valuable insights from the literature include the need for a clear vision around governance aims; the importance of ensuring that policy dialogue processes are inclusive and transparent, avoiding interest group capture; the benefits of exploiting synergies between governance mechanisms; and the need to develop capacity to enact governance among both public and private actors.ConclusionGovernance choices shape not just the current health system, but also its future development. Common barriers to effective governance must be addressed in policy design, stakeholder engagement, public and private sector accountability, monitoring and capacity. Achieving this will require in-depth explorations of governance mechanisms and more rigorous documentation of implementation and outcomes in diverse contexts.

Project description:ObjectiveTo understand barriers and facilitators for strengthening health systems for person-centred care of people with multiple long-term conditions-multimorbidity (MLTC-M) at the primary healthcare (PHC) level in low-income and middle-income countries (LMICs).DesignA scoping review.MethodsWe adopted a systematic scoping review approach to chart literature guided by Arksey and O'Malley's methodological framework. The review focused on studies conducted in LMICs' PHC settings from January 2010 to December 2023. Papers were extracted from the following databases: PubMed, EBSCOhost and Google Scholar. Framework analysis was undertaken to identify barriers and facilitators for strengthening MLTC-M primary care according to the five health system pillars in the Lancet Global Health Commission on High-Quality Health Systems Framework.ResultsThe literature search yielded 4322 citations, evaluated 202 studies and identified 36 for inclusion. Key barriers within the people pillar included poverty, low health education and low health literacy; within the platform pillar, fragmented services and lack of multimorbid care guidelines were mentioned; within the workforce pillar, lack of required skills and insufficient health workers; and in the tools pillar: a shortage of essential medicines and adverse polypharmacy effects were prominent. A lack of political will and the absence of relevant national health policies were identified under the governance pillar. Facilitators within the people pillar included enhancing self-management support; within the platforms, pillar included integration of services; within the tools pillar, included embracing emerging technologies and information and communication technology services; and governance issues included upscaling interventions to respond to multimorbid care needs through enhanced political commitment and financial support.ConclusionsPotential solutions to strengthening the healthcare system to be more responsive to people with MLTC-M include empowering service users to self-manage, developing multimorbid care guidelines, incorporating community health workers into multimorbid care efforts and advocating for integrated person-centred care services across sectors. The need for policies and procedures in LMICs to meet the person-centred care needs of people with MLTC-M was highlighted.

Project description:BackgroundQuality of care is essential for further progress in reducing maternal and newborn deaths. The integration of educated, trained, regulated and licensed midwives into the health system is associated with improved quality of care and sustained decreases in maternal and newborn mortality. To date, research on barriers to quality of care for women and newborns has not given due attention to the care provider's perspective. This paper addresses this gap by presenting the findings of a systematic mapping of the literature of the social, economic and professional barriers preventing midwifery personnel in low and middle income countries (LMICs) from providing quality of care.Methods and findingsA systematic search of five electronic databases for literature published between January 1990 and August 2013. Eligible items included published and unpublished items in all languages. Items were screened against inclusion and exclusion criteria, yielding 82 items from 34 countries. 44% discussed countries or regions in Africa, 38% in Asia, and 5% in the Americas. Nearly half the articles were published since 2011. Data was extracted and presented in a narrative synthesis and tables. Items were organized into three categories; social; economic and professional barriers, based on an analytical framework. Barriers connected to the socially and culturally constructed context of childbirth, although least reported, appear instrumental in preventing quality midwifery care.ConclusionsSignificant social and cultural, economic and professional barriers can prevent the provision of quality midwifery care in LMICs. An analytical framework is proposed to show how the overlaps between the barriers reinforce each other, and that they arise from gender inequality. Links are made between burn out and moral distress, caused by the barriers, and poor quality care. Ongoing mechanisms to improve quality care will need to address the barriers from the midwifery provider perspective, as well as the underlying gender inequality.

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Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review

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